=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114562667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGEVITY RESIDENTIAL CARE II
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2019
-----------------------------------------------------
Last Update Date | 11/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4073 KINGS ROW
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89503-6825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-622-9982
-----------------------------------------------------
Fax | 775-622-9630
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4073 KINGS ROW
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89503-6825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-622-9982
-----------------------------------------------------
Fax | 775-622-9630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. SAMMY VALERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-843-9421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------